HomeMy Public PortalAbout9002 GARIBALDI AVE_Plumbing__ 2D-OM DM
WORKER'S 'S""°ND `"6entt" 7&AM7A °/�° APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a pertlfloate of oon►ent to self Insure, 76AEa7A '
or a certlifaate of Workerq Compensation Insurance, or a certhled
�thereof•(Seo.3900 Lab.C,) r
ry � COUNTY OF LOS ANGELES DEPT.OF:PUBLIO WORKS DEPT.OF PUBLIC WORKS DIV.
❑ CwMad copy b hereby futr*Owd. FOR APPLJCAHT TO FILL N(PR?lT OR TYPQ
ADDRESS
❑' z
skid with the=xq bur
NUMBER FDCR)RE OR rrHl • Fly LOCAIlTY
App+oirrt WATER CLOSET NF. BT
CROSS ST.
FICATE OF D0IPTFON FFION WORD' BATI1 TUB
COMPENSATION INSURANCE MAS gpp� PAC3E PARCEL.
(This Mottos. nsn
riot be compist d tf the ort tnvotred try the SHOW
permftAs for one hundred doGers(S 100)or lees.) OWNS
I o6"that In the performance of the work for whloh this permitMAJL
LAVATORY
Is I4susd, I shall riot employ any person In any manner so as to SNC
beddme sub)eat to the Workers'Compensation taws.
DiSWA%:ER CITY TEL NO.
D&B Ap1—a CLOTHES WASHER
NOTICE TO APP41CANT: If, after making this Cartlfloate of
Exemption,you should begone apb)ect to the Workers'C xnpenaddan SWLLS 4G POOL F8CE'TOR
ptov[sloni of thr Labor Cods,you must forthwto oomply with euoh YS
provisions or this h shall be d6efned re"ked. LAWN BpRtNtO..ffl SYS>fll
LPCENStD COfJTRACTORS DECLARATION T� 8-
I hereby aMrrtl that I am lloensed under provisions of Chapter 9 WATER HEATER
(oommencing with Beotlon 7000)of Divlslon 3 of the Business apo GAB 9YHT�1 STATE
NO. a�igg
Professions Code,and my lidera Is IrLfuII for*4nd effect
OUTLET'S�� DISTFitCT NO. PROCE68ED BY
55S6 SYSTEM
Lkxrus Number Lk�.Claw
FINAL
DATE VALIDATION
tea«L DATE
IrJ I am exempt under Bea FrNALBY l
B SP.C.forthb reason -
Plan chw*fee
. Dein:
e PLUMBING PEAMFISWINO FEES G Q 1111p. }
TOTAL FES
❑ Plan cfleok appkeM 3303 y 1 M 41'K-
81N131�FAMILI' ITLI F7
HOME OWNER-BUILDER DECLARATION Name
I hereby attlrm that I alt exempt from tne-Contrabtors Lloshse Lawes'
too tha following reason (Section 7031.6, Buslness and Professions ,Adana.. �TIJ)T•��A++t �Jc
rwr L�r 4 1'- 3
Code): T61"No. cw4it 41■
❑ I,is dwof the property,will do the work and the airuoturs I��Ltn1V��
is not Intended or offered for Bale (Beptlon -1044, Business `�!'a'
and Professbne Code). , a
CONSTRUCTION LENDING AGENCY - C�QO�t11 11/ 1/94
1 hefeby affirm that there Is a oonstructlon Iendlhg agenoy for the Yy
performange of the wo&for which this permit Is Issued (Seo. 3097, l r17 1 PM 2:lA1
Ctv.C.) 1 ;
. L ..
LerpWs Nemo
Lenders Address
I certify that I haw read this epplloatlon and state that the above
Information Is oorreaL I agree to oompty with all-County ordlnahoes
and State laws regulating Plumbing, and hereby ■uthorLts
Tntattvee of thla u o enter upon the above-mentlonsd or pus r BEE REVERSE FOR EXP~T0f3Y LANGUAfIE
Slprsa " ofDidbe
WO B COMPENSATION bECt_AAATION �DPW 9189
I�hersby affirm that I have a asrUftate of consent to self Insure, APPLICATION_ FOR PLUMBING PERMIT u
or a oerttflo)tta cf Viorkers Compensatton Insuranoe, or a oertifled
copy t (Seo.3800 Lab.C.)
COUWTY.OF LOS AdJMES ,QEPT:QF PUBLIC WORKS DEBT.OF PUBLIC WOA"M.
po"
❑ Certified copy Is hereby furrrYfbd. ' BIADlNO
FOR APPLICANT TO FILL IN(PRINT bR TYPES ASS-
Certified copy b f0ed with the oaurty bufidng
dMArtmQqL NUMBER FDRURE OR r181 / • FEE IACALrTY
Dais APploartt EA) WATER CLOSET
NEAREST
CROW ST.
CEAT1FiCAl'E OF EJO�APT)ON FROM yYOR�s' BATH TL18 ABSE96oR
COWPENBAT}ON INSURANCE
(This section need not be"plated if the srorfi Invofv�4 by the W 8004( PALS PARCEL
permit b for one hundred dollars(;100)or leis.) pVyPg� Q�1tM1�
I o tlfy that In the performance of[hp work for which this permit LAVATORY v V 0
Is Issuo, I shall not employ 4ny person In any manner so as td SINK NAIL 0
beoome dubleot to the Wor}cers'.Com penestton Laws.
t 4L8WAS"'R CITY I
Date Appk6rd CLOTHES WASHERw 4
iw
NOTICE 'fO AIPPLICANT: If, after making this CertIfloate of N
Exemption,you ahoukf become subjW to the•Wbdwq'Compenm0on eWIMAQNO POOL REC�TOR ADDRESS
provisions of the Labor Cod9, you must forthwith ootnp(y with such
qvo
provisions or this psrmtt shall be dgemed revoked. LAWN SPEER SYSTEM 4A 114
UCE
TION
I hereby affirm that IIggm Ilcd under provisions oonss of Chapter p WATER HEATER (L
(oommencing with 8bctlon 70M of DMelon 3 of the Business end &LI SE NO CLLICASS ,+ 8
Profepal na Code,and my Iloenee Is In full force and effea GAS BYBT $
OUTlFfB pygf DWTRICT NO. PF ocMlED BY ([
L k)wm Number
�� dd _ VALUAlhON
D mete FfNAi 330,7 2'93.1 +CO
I an, under s.o.
BY
I TE1'1J —
8.&P-C.for this reason Plan check fee TOTAL 293-' 10
I3etx +
- PLUMBING PERMIT ISSUING FSE; 293.113
- TOTAL FEE � ¢ •Ce-1
D SJNOI FAMILY -"1
t '
HOME OWN Ef}BUILDF7d DECLARATION N" '
1�} 0-1] 131 4l 1?�'g 4
I hereby affirm that I am exempt from the Contrsators Lloenee Law 11 o At
for the following reason(flection 7031.5, Business and Professions Address k .5 rf t 7 775
Code):
City Td.No. �
I, ee owner of the property,will do brie Norio and the structure
fa not Intended or offered for We (8eCtlon 7044, Business
and Professions Code). '
CONSTAUCTiON LENDING AGENCY
I hs4by afflrm thsl there Is a oonstruction lending agency for the
performance of the work for Whldtf this permit is Issued (8e0. 3087,
Chi.C.)
Lenders Nail,
Landers Address
4 oertlfy that I Tuve read this application and state that the above Poo.
Is oonvOt I agree to comply with all County ordlnanoee
and State laws reou gmbing, and hereby authorize
re
pr w of County to enter upon the above-mentioned
f pro I purpbses SEE REVERSE POR EXPUNATORY LANGUAGE
lgnelture of Pefmfttee_ Deft